1. The role of Pediatric Environmental Health Specialty Units (PEHSU): Collaboration and Expertise Jennifer Lowry, MD Director, Mid-America Pediatric Environmental Health Specialty Unit Children’s Mercy Hospital Kansas City, MO

2. Disclaimer This presentation was prepared by the Association of Occupational and Environmental Clinics (AOEC) and funded (in part) by the cooperative agreement award number 1U61TS000118-05 from the Agency for Toxic Substances and Disease Registry (ATSDR). Acknowledgement: The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.

3. Mission Improve the environmental health of children by: Enhancing educational and consultative services to clinicians, health professionals and the community. Providing evidence-based information from a network of experts in environmental health.

4. PEHSU History 1996 ATSDR Child Health Initiative - emphasis on environmental hazards to children’s health. The first PEHSU programs were established in 1998 in Seattle and Boston following two, large environmental exposure incidents: –1995 to 1996 mercury exposure factory converted to apartments in New Jersey. 1 –1996 to1998 methyl parathion exposure potentially affecting 400+ children in Illinois, Mississippi and Ohio.

5. What is a PEHSU? A PEHSU site is a collaboration between an Association of Occupational and Environmental Clinic (AOEC) member clinic and an academic pediatric program. A typical PEHSU staff includes a project director, a coordinator, an occupational environmental medicine physician, a pediatrician, and often other specialists such as a toxicologist or industrial hygienist.

6. PEHSU Services Consultation for clinicians/health professionals regarding children’s environmental health concerns. Education/Outreach on pediatric environmental health provided to clinicians/health professionals, clinical trainees and the general public. Referral to appropriate resources for children with environmental health needs.

7. Funding and Management of Agency for Toxic Substances and Disease Registry (ATSDR) U.S. Environmental Protection Agency (EPA) Association of Occupational & Environmental Clinics (AOEC)

8. PEHSU Site Locations www.pehsu.net (or 1-888-347-2632) www.pehsu.net Region 1: Boston, MA Region 2: New York, NY Region 3: Washington, DC Region 4: Atlanta, GA Region 5: Chicago, IL and Cincinnati, OH (satellite location) Region 6: Tyler, TX Region 7: Kansas City, MO Region 8: Denver, CO Region 9: Irvine and San Francisco, CA Region 10: Seattle, WA Alberta, Canada Guadalajara, Mexico

9. Boston Children’s Hospital Boston Cambridge Hospital New York City Mount Sinai Medical Center Washington DC Children’s National Medical Center Atlanta Children’s Healthcare of Atlanta Egleston Children’s Hospital Hughes Spalding Children’s Hospital Tyler University of Texas Health Science Center Edmonton Misericordia Community Hospital Kansas City Children’s Mercy Hospitals and Clinics San Francisco University of California Hospital Seattle Harborview Medical Center University of Washington Medical Center Children’s Hospital and Regional Medical Center Denver National Jewish Medical and Research Center Denver Health and Hospitals Chicago Stroger Hospital of Cook County Irvine Irvine Medical Center Guadalajara University of Guadalajara Health Sciences Center Pediatric Environmental Health Specialty Units (PEHSU) In North America - Hospital Affiliations Canada Mexico Alaska Hawaii Virgin Islands Puerto Rico

10. PEHSU 2012 Annual Report, October 2013

14. Website: www.pehsu.net

15. PEHSU Factsheets

16. What is Pediatric Environmental Health?

17. Pediatric Environmental Health A discipline that involves the identification, treatment, prevention and control of environmental exposures and associated adverse health effects in infants, children, adolescents, and young adults http://www.aap.org/healthtopics/environmentalhealth.cfm

18. Cumulative risk Poverty Lead Allergens Poor nutrition Stressed mother Noise Squalid neighborhood No parks From Lecture of Dr. Howard Frumkin

19. Variations in Susceptibility with Developmental Stages Preconception Fetus Newborns Infants Toddlers (1-2 yrs) Young Child (2-6) School Aged (6-12 ) Adolescents (12-18)

20. Disparities in Environmental Exposures Hood, E. (2005). "Dwelling disparities: how poor housing leads to poor health." Environ Health Perspect 113(5): A310-7

21. 21 Lead SOURCE: Meyer PA, et al. Surveillance for elevated blood lead levels among children--United States, 1997-2001. MMWR 2003;52(SS10):1-21.

22. 22 Air quality Source: Wernette DR, Nieves LA. Breathing polluted air: minorities are disproportionately exposed. EPA Journal 1992;18:16-17

23. 23 Asthma and Equity Asthma prevalence twice as high, and mortality three times as high, in blacks as in whites Asthma prevalence 3x higher in Hispanic than non-Hispanic children Asthma hospitalization among Medicaid children: 93%  in blacks, 34%  in Hispanics, compared to whites

24. Extent of knowledge Grandjean P and Landrigan PJ, Lancet. 2006 More than 80,000 chemicals registered with EPA Greatest risk are 2,863 high- production-volume (HPV) chemicals (produced in amounts of 1 million pounds or more per year) Fewer than half have been tested for Toxicity to Human Health Less than 10% have been tested for pediatric neurotoxicity Gaps in knowledge are particularly great in regard to developmental toxicity

25. 25 Effect of Removing Lead From Gasoline Blood Lead Levels in US

26. Lead Poisoning No level of lead in the blood is safe. In December 2012, the United States Centers for Disease Control and Prevention (CDC) established a new “reference value” for blood lead levels (5 mcg/dL), thereby lowering the level at which evaluation and intervention are recommended In 2013, the CDC also defunded childhood lead poisoning prevention programs across the US resulting in the inability for state and local health departments to respond to the increasing numbers of lead poisoned children.

27. Lead Poisoning Health care professional as advocate Environmental education in US medical schools is limited despite agreement that increased emphasis is needed. Past reliance on health departments has resulted in decreased awareness of environmental exposures and their management.

28. Case A health care professional (HCP) notified the regional PEHSU regarding a child with a BLL of 25 mcg/dL. Officials at the local and state health department had mentioned that nothing could be done due to lack of resources given the recent loss of funding from the CDC. Regional PEHSU determined that the child’s exposure was a result of the father’s work in print shop that used lead ink. The father’s screening BLL was above 100 mcg/dL revealing the extent of exposure to the child. Officials with the Occupational Safety and Health Administration (OSHA) became involved to assess other shop workers and their children. Testing of other employees and their families is ongoing

29. Study Aims and Methods Aim: To investigate trends in US PESHU lead contacts Methods: –A retrospective study of PEHSU contacts between 1/1/2007 and 12/31/2012 –Seasonal and regional trends in lead contacts were analyzed along with patterns in location of lead exposure, route of exposure, patient geographic location, referral source, patient age and gender.

30. Results Lead was overwhelmingly the primary topic of concern (between 27-35% annually) More than 78.5% of calls or referrals to PEHSU’s were from health care professionals. –The majority of calls from HCP regarded children aged 2-5 years. –The majority of exposures (70%) occurred in the home setting. This included work exposures being brought home to children. Outreach activities were primarily focused on established health care professional training rather than student/trainee education.

31. Age of Patient AgesPercentage of total calls Prenatal0.71% 0 - 11 months8% 12 - 23 months26.2% 2 – 5 years45.7% 6 – 9 years7.5% 10 - 13 years3% 14 – 18 years2.6% 19 years0.4% Adult0.6% Unknown age4.1%

32. Results Exposure SettingPercentage of Total Home79.5% Work/School/Public Area/Daycare1.05% Unknown19.4% Caller informationPercentage of Total Health Care Professional40.7% Parents/Grandparents55.2% Parents referred by HCP to call67% of the 55%

33. Limitations Retrospective review of data Incomplete data as reliance on data entry Underrepresentation of exposures as dependent on calls to PEHSU

34. Conclusions Lead remains a serious threat to children in the US and worldwide Medical and public health communities continue to have questions regarding environmental exposures in children. The majority of environmental calls to PEHSUs are regarding home exposures With lack of public health funding, PEHSUs may be relied upon for this information.

35. Questions?